<!DOCTYPE html PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN" "http://www.w3.org/TR/html4/loose.dtd">
<html>
<head>
<meta http-equiv="Content-Type" content="text/html; charset=UTF-8">
<title>Insert title here</title>
<style>

#patientform{
	width:45%;
}
#patientform h2{
	color: #353431;
	font-size: 1.6em;
	margin-bottom: 9px;
	padding-top: 7px;
	padding-right: 0pt;
	padding-bottom: 4px;
	padding-left: 35px;
	background-color: transparent;
	background-image: url(/brahma/img/avatar.png);
	background-repeat: no-repeat;
	background-attachment: scroll;
	background-position: 0pt 50%;
}
#patientform label{
	color: #666666;
	display: block;
	font-size: 12px;
	font-weight: bold;
	float: left;
	padding-top: 6px;
	padding-right: 10px;
	padding-bottom: 0pt;
	padding-left: 0pt;
	text-align: right;
	width: 130px;
}
#patientform .keeper label{
	color: #666666;
	display: inline;
	font-size:12px;
	float: none;
}
#patientform input.code{
	border-top-width: 2px;
	border-right-width-value: 2px;
	border-right-width-ltr-source: physical;
	border-right-width-rtl-source: physical;
	border-bottom-width: 2px;
	border-left-width-value: 2px;
	border-left-width-ltr-source: physical;
	border-left-width-rtl-source: physical;
	border-top-style: inset;
	border-right-style-value: inset;
	border-right-style-ltr-source: physical;
	border-right-style-rtl-source: physical;
	border-bottom-style: inset;
	border-left-style-value: inset;
	border-left-style-ltr-source: physical;
	border-left-style-rtl-source: physical;
	border-top-color: white;
	border-right-color-value: white;
	border-right-color-ltr-source: physical;
	border-right-color-rtl-source: physical;
	border-bottom-color: white;
	border-left-color-value: white;
	border-left-color-ltr-source: physical;
	border-left-color-rtl-source: physical;
	background-color: white;
	color: black;
	color: #333333;
	font-size: 14px;
	font-weight: bold;
	height: 25px;
	padding-top: 5px;
	padding-right: 6px;
	padding-bottom: 0px;
	padding-left: 6px;
	width: 100px;
	vertical-align: middle;
}
#patientform input.text{
	border-top-width: 2px;
	border-right-width-value: 2px;
	border-right-width-ltr-source: physical;
	border-right-width-rtl-source: physical;
	border-bottom-width: 2px;
	border-left-width-value: 2px;
	border-left-width-ltr-source: physical;
	border-left-width-rtl-source: physical;
	border-top-style: inset;
	border-right-style-value: inset;
	border-right-style-ltr-source: physical;
	border-right-style-rtl-source: physical;
	border-bottom-style: inset;
	border-left-style-value: inset;
	border-left-style-ltr-source: physical;
	border-left-style-rtl-source: physical;
	border-top-color: white;
	border-right-color-value: white;
	border-right-color-ltr-source: physical;
	border-right-color-rtl-source: physical;
	border-bottom-color: white;
	border-left-color-value: white;
	border-left-color-ltr-source: physical;
	border-left-color-rtl-source: physical;
	background-color: white;
	color: black;
	color: #333333;
	font-size: 12px;
	font-weight: bold;
	height: 16px;
	padding-top: 5px;
	padding-right: 6px;
	padding-bottom: 0px;
	padding-left: 6px;
	width: 241px;
	vertical-align: middle;
}
#patientform input.short{
	width:40px;
}
#patientform fieldset.buttons p{
	padding-right: 34px;
	}

#patientform p.small{
	font-size: small;
	text-align: center;
	padding-right: 15px;
}
#patientform p.right{
	font-size: small;
	text-align: right;
	padding-right: 40px;
}

#patientform input.submit{
	float:right;
	
}
</style>
</head>
<body>

<div id="patientform">
		
			<form  ACCEPT-CHARSET="UTF-8" name="patient" action="" method="post">
				<fieldset class="inputs">
				<legend>Nouveau Patient</legend>
					<p>
						<label for="nom">Nom</label> 
						<input name="nom" id="nom" class="text" title="nom du patient" alt="nom du patient" type="text" value="">
					</p>
					<p>
						<label for="prenom">Prenom</label> 
						<input name="prenom" id="prenom" class="text" title="prenom du patient" alt="prenom du patient" type="text" value="">
					</p>
					<p>
						<label for="rue">Rue</label> 
						<input name="rue" id="rue" class="text" title="rue du patient" alt="rue du patient" type="text" value="">
					</p>
					<p>
						<label for="numero">N°</label> 
						<input name="numero" id="numero" class="text short" title="numero du patient" alt="numero du patient" type="text" value="">
					</p>
					<p>
						<label for="boite">Boite</label> 
						<input name="boite" id="boite" class="text short" title="boite du patient" alt="boite du patient" type="text" value="">
					</p>
					<p>
						<label for="cp">Code Postal</label> 
						<select name="cp" id="cp" class="lst" title="Code postal du patient" alt="Code postal du patient" >
							<option class="opt" value="4000">4000 Liège</option>
							<option class="opt" value="4020">4020 Liège</option>
						</select>
					</p>
					<p>
						<label for="natio">Nationalité</label> 
						<input name="natio" id="natio" class="text" title="Nationalité du patient" alt="Nationalité du patient" type="text" value="">
					</p>
					<p>
						
							<label for="ddn">Naissance</label>
							<div id="ddn">
								<select name="day" id="day" class="lst" title="Jour de naissance du patient" alt="Jour de naissance du patient" >
									<option class="opt" value="1">1</option>
									<option class="opt" value="2">2</option>
								</select>
								
								
								<select name="month" id="month" class="lst" title="Mois de naissance du patient" alt="Mois de naissance du patient" >
									<option class="opt" value="1">Janvier</option>
									<option class="opt" value="2">Fevrier</option>
								</select>
								
								
								<select name="year" id="year" class="lst" title="Année de naissance du patient" alt="Année de naissance du patient" >
									<option class="opt" value="1977">1977</option>
									<option class="opt" value="1978">19778</option>
								</select>
						</div>
					</p>
					<p>
						<label for="phone">Fixe</label> 
						<input name="phone" id="phone" class="text" title="Téléphone fixe du patient" alt="Téléphone fixe du patient" type="text" value="">
					</p>
					<p>
						<label for="mobile">Mobile 1</label> 
						<input name="mobile" id="mobile" class="text" title="Téléphone mobile du patient" alt="Téléphone mobile du patient" type="text" value="">
					</p>
					<p>
						<label for="mobile2">Mobile 2</label> 
						<input name="mobile2" id="mobile2" class="text" title="Second téléphone mobile du patient" alt="Second téléphone mobile du patient" type="text" value="">
					</p>
					<p>
						<label for="fax">Fax</label> 
						<input name="fax" id="fax" class="text" title="Fax du patient" alt="Fax du patient" type="text" value="">
					</p>
					<p>
						<label for="email">E-mail</label> 
						<input name="email" id="email" class="text" title="E-mail du patient" alt="E-mail du patient" type="text" value="">
					</p>
					<p>
						<label for="mutu">Mutuel</label> 
						<select name="mutu" id="mutu" class="lst" title="Mutuel du patient" alt="Mutuel du patient" >
								<option class="opt" value="1977">mutuel libre</option>
								<option class="opt" value="2">mutuel socialiste</option>
						</select>
					</p>
					<p>
						<label for="num_mutu">Num. Mutuel</label> 
						<input name="num_mutu" id="num_mutu" class="text" title="Numéro de mutuel du patient" alt="Numéro de mutuel du patient" type="text" value="">
					</p>
					<p>
						<label for="job">Profession</label> 
						<input name="job" id="job" class="text" title="Profession du patient" alt="Profession du patient" type="text" value="">
					</p>
					<p>
						<label for="comm">Commentaires</label> 
						<textarea name="comm" id="comm" class="txtzone" title="Commentaires au sujet du patient" alt="Commentaires au sujet du patient" type="text" value=""></textarea>
					</p>
				</fieldset>
				<fieldset class="buttons">
					<p>
						<input type="submit" value="Sauvegarder" alt="Sauvegarder" title="Sauvegarder" class="submit">
					</p>
				</fieldset>
				
				
			</form>
	</div>
</body>
</html>